8802 Application for United States

8802 Form

(Rev. November 2018)

Department of the Treasury Internal Revenue Service

Application for United States Residency Certification

See separate instructions.

Important. For applicable user fee information, see the Instructions for Form 8802.

Additional request (see instructions)

Foreign claim form attached

Electronic payment confirmation no.

OMB No. 1545-1817

For IRS use only:

Pmt Amt $

.

Deposit Date:

/ /

Date Pmt Vrfd: / /

Applicant's name

Applicant's U.S. taxpayer identification number

If a joint return was filed, spouse's name (see instructions)

If a joint return was filed, spouse's U.S. taxpayer identification number

If a separate certification is needed for spouse, check here 1 Applicant's name and taxpayer identification number as it should appear on the certification if different from above

2 Applicant's address during the calendar year for which certification is requested, including country and ZIP or postal code. If a P.O. box, see instructions.

3a Mail Form 6166 to the following address:

b Appointee Information (see instructions):

Appointee Name

Phone No. (

)

CAF No.

Fax No. (

)

4 Applicant is (check appropriate box(es)):

a

Individual. Check all applicable boxes.

U.S. citizen

U.S. lawful permanent resident (green card holder)

Sole proprietor

Other U.S. resident alien. Type of entry visa

Current nonimmigrant status

and date of change (see instructions)

Dual-status U.S. resident (see instructions). From

to

Partial-year Form 2555 filer (see instructions). U.S. resident from

to

b

Partnership. Check all applicable boxes.

U.S.

Foreign

LLC

c

Trust. Check if:

Grantor (U.S.)

Simple

Rev. Rul. 81-100 Trust

IRA (for Individual)

Grantor (foreign)

Complex

Section 584

IRA (for Financial Institution)

d

Estate

e

Corporation. If incorporated in the United States only, go to line 5. Otherwise, continue.

Check if:

Section 269B

Section 943(e)(1)

Section 953(d)

Section 1504(d)

Country or countries of incorporation

If a dual-resident corporation, specify other country of residence

If included on a consolidated return, attach page 1 of Form 1120 and Form 851.

f

S corporation

g

Employee benefit plan/trust. Plan number, if applicable

Check if:

Section 401(a)

Section 403(b)

Section 457(b)

h

Exempt organization. If organized in the United States, check all applicable boxes.

Section 501(c)

Section 501(c)(3)

Governmental entity

Indian tribe

Other (specify)

i

Disregarded entity. Check if:

LLC

LP

LLP

Other (specify)

j

Nominee applicant (must specify the type of entity/individual for whom the nominee is acting)

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 10003D

Form 8802 (Rev. 11-2018)

Form 8802 (Rev. 11-2018)

Applicant name:

5 Was the applicant required to file a U.S. tax form for the tax period(s) on which certification will be based?

Yes. Check the appropriate box for the form filed and go to line 7.

990

990-T

1040

1041

1065

1120

1120S

3520-A

Other (specify)

5227

Page 2

5500

No. Attach explanation (see instructions). Check applicable box and go to line 6.

Minor child

QSub

U.S. DRE

Foreign DRE

FASIT

Foreign partnership

Other

Section 761(a) election

6 Was the applicant's parent, parent organization or owner required to file a U.S. tax form? (Complete this line only if you checked "No" on line 5.)

Yes. Check the appropriate box for the form filed by the parent.

990

990-T

1040

1041

1065

1120

1120S

5500

Other (specify) Parent's/owner's name and address

and U.S. taxpayer identification number No. Attach explanation (see instructions). 7 Calendar year(s) for which certification is requested. Note. If certification is for the current calendar year or a year for which a tax return is not yet required to be filed, a penalties of perjury statement from Table 2 of the instructions must be entered on line 10 or attached to Form 8802 (see instructions).

8 Tax period(s) on which certification will be based (see instructions).

9 Purpose of certification. Must check applicable box (see instructions).

Income tax

VAT (specify NAICS codes)

Other (must specify)

10 Enter penalties of perjury statements and any additional required information here (see instructions).

Sign here

Under penalties of perjury, I declare that I have examined this application and accompanying attachments, and to the best of my knowledge and belief, they are true, correct, and complete. If I have designated a third party to receive the residency certification(s), I declare that the certification(s) will be used only for obtaining information or assistance from that person relating to matters designated on line 9.

Applicant's signature (or individual authorized to sign for the applicant)

Keep a

copy for your records.

Signature

Date

Applicant's daytime phone no.:

Name and title (print or type)

Spouse's signature. If a joint application, both must sign.

Name (print or type)

Form 8802 (Rev. 11-2018)

Form 8802 (Rev. 11-2018) Applicant Name

Worksheet for U.S. Residency Certification Application

Applicant TIN

Page 3

Appointee Name (If Applicable)

Calendar year(s) for which certification is requested (must be the same year(s) indicated on line 7)

11 Enter the number of certifications needed in the column to the right of each country for which certification is requested. Note. If you are requesting certifications for more than one calendar year per country, enter the total number of certifications for all years for each country (see instructions).

Column A

Column B

Column C

Column D

Country

CC #

Country

CC #

Country

CC #

Country

CC #

Armenia

AM

Finland

FI

Latvia

LG

South Africa

SF

Australia

AS

France

FR

Lithuania

LH

Spain

SP

Austria

AU

Georgia

GG

Luxembourg

LU

Sri Lanka

CE

Azerbaijan

AJ

Germany

GM

Mexico

MX

Sweden

SW

Bangladesh

BG

Greece

GR

Moldova

MD

Switzerland

SZ

Barbados

BB

Hungary

HU

Morocco

MO

Tajikistan

TI

Belarus

BO

Iceland

IC

Netherlands

NL

Thailand

TH

Belgium

BE

India

IN

New Zealand

NZ

Trinidad and Tobago TD

Bermuda

BD

Indonesia

ID

Norway

NO

Tunisia

TS

Bulgaria

BU

Ireland

EI

Pakistan

PK

Turkey

TU

Canada

CA

Israel

IS

Philippines

RP

Turkmenistan

TX

China

CH

Italy

IT

Poland

PL

Ukraine

UP

Cyprus

CY

Jamaica

JM

Portugal

PO

United Kingdom

UK

Czech Republic

EZ

Japan

JA

Romania

RO

Uzbekistan

UZ

Denmark

DA

Kazakhstan

KZ

Russia

RS

Venezuela

VE

Egypt

EG

Korea, South

KS

Slovak Republic

LO

Estonia

EN

Kyrgyzstan

KG

Slovenia

SI

Column A - Total

Column B - Total

Column C - Total

Column D - Total

12 Enter the total number of certifications requested (add columns A, B, C, and D of line 11) . . . . . . . . . . Form 8802 (Rev. 11-2018)

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